EVALUATING the RELATIONSHIP BETWEEN ANXIETY SCORES and NUTRIENT INTAKE in UNDERGRADUATE COLLEGE STUDENTS a Thesis Submitted To

EVALUATING THE RELATIONSHIP BETWEEN ANXIETY SCORES AND NUTRIENT INTAKE IN UNDERGRADUATE COLLEGE STUDENTS

A thesis submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Master of Science

Isabella T. Biasi

Fall 2019

A thesis written by Isabella Teresa Biasi

B.S., Kent State University, 2018

M.S., Kent State University, 2019

Approved by

______, Director, Master’s Thesis Committee Natalie Caine-Bish

______, Member, Master’s Thesis Committee Karen Lowry Gordon

______, Member, Master’s Thesis Committee Jamie Matthews

Accepted by

______, Director, School of Health Sciences Ellen Glickman

______, Dean, College of Education, Health, and Human James C. Hannon Services

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BIASI, ISABELLA TERESA, M.S., December 2019 Nutrition and Dietetics

EVALUATING THE RELATIONSHIP BETWEEN ANXIETY SCORES AND NUTRIENT INTAKE IN UNDERGRADUATE COLLEGE STUDENTS (69 pp.)

Director of Thesis: Natalie Caine-Bish, Ph.D, R.D., L.D

College students tend to have high levels of anxiety related to financial, academic, and social stressors. This can cause issues with their nutrient intake. It is hard to balance school, a social life, and work so often times, dietary consumption is put on the back burner. The purpose of this correlational study was to evaluate the relationship between anxiety scores and nutrient intake in college students. Participants were limited to undergraduate students at Kent State University’s main campus. They were between the ages of 18-24 years old and not have had a current medical diagnosis for anxiety. The students had to complete a three-part survey consisting of demographics, an anxiety scale, and a 24-hour dietary recall. The data was analyzed by using descriptive statistics and Pearson’s correlation. Analysis of the data showed a significant relationship between anxiety level and fat intake (r=.207, p=.046). The data showed that there was not a significant relationship between anxiety level and calories, carbohydrates, protein, sugar, or sodium. The significant relationship found between anxiety level and fat intake was supported by previous research.

ACKNOWLEDGEMENTS I would like to thank Dr. Natalie Caine-Bish for her guidance during this process.

Dr. Bish provided great advice and I have learned a great deal about the writing process, research methods, and statistics. She believed that I could accomplish this goal of completing a Master’s Thesis and that gave me the confidence to finish it. I appreciate all of the time and effort she has put into guiding me throughout this process.

I would also like to thank Dr. Karen Gordon and Jamie Matthews for their help and advice. Their knowledge on the research and writing process helped me to complete this

Thesis. I have learned so much from them as well.

Lastly, I would like to thank the undergraduate students at Kent State University who participated in the survey I distributed. Data collection would have been set back if they did not so willingly participate.

TABLE OF CONTENTS Page

ACKNOWLEDGMENTS…………………………………………………………..……iv

LIST OF TABLES……………………………………………………………………….vii

CHAPTER

I. INTRODUCTION……………………………………………………………………...1 Statement of the Problem……………………………………………………………….2 Purpose Statement ……………………………………………………………………...4 Hypotheses……………………………………………………………………………...4 Operational Definitions…………………………………………………………………4

II. REVIEW OF THE LITERATURE Current Dietary Intake of Americans…………………………………………………...6 Recommendations of Dietary Intake of Adults……………………………...…….7 Calories………………………………………………………………………....7 Carbohydrate……....……………………………………………………………9 Fat…………………………………...……………………………………...... 10 Protein………………………...……………………………………………….11 Anxiety………………………………………………………………………………...12 Generalized Anxiety Disorder (GAD)…....…………………………………...... 13 Panic Disorder………………...………………………………………………….14 Social Phobia Disorder…………………………………………………………...14 Specific Phobia Disorder…………………………………………………………15 Anxiety Treatments…………....……………………………………………...... 15 Anxiety and Depression…………………………………………………………..17 Anxiety and Bipolar Disorder…………………………………………………….18 Anxiety and Eating Disorders…………………………………………………….19 Anxiety and Obesity……………………………………………………………...22 College Students and Anxiety………………………………………………...... 24 College Students and Dietary Intake……………………………………………...26 Types of Food and Amount Consumed When Experiencing Anxiety…………...28

III. METHODOLOGY Overview……………………………………………………………………………..31 Participants……………………………………………………………………...……31 Survey Components………………………………………………………………….31 v

Part I: Demographics/dietary intake…………...……………………………...32 Part II: GAD – 7 anxiety scale…………………………………………...…… 32 Part III: 24-hour dietary recall………………………………………………...33 Data Collection Procedures…………………………………………………………..34 Data Analysis Procedures……………………………………………………………35

IV. JOURNAL ARTICLE Introduction………………………………………………………………………..…37 Methodology…………………………………………………………………………38 Instrumentation……………………………………………………………...... 39 Data Collection Procedures……………………………………………….…….40 Data Analysis Procedures……………………………………………….…...... 41 Results………………………………………………………………………………..41 Discussion…………………………………………………………………………....44 Limitations…………………………………………………………………………...46 Applications………………………………………………………………………….47 Conclusion…………………………………………………………………………...47

APPENDICES…………………………………………………………………………...49 APPENDIX A. IRB Approval E-mail…………..…………………...…………….50 APPENDIX B. Demographic Questions and GAD-7 Anxiety Scale...... 52 APPENDIX C. Recruitment E-mail……….………………………....…………….57 APPENDIX D. Study Consent Form ………………………………...…………….59

REFERENCES…………………………………………………………………………..61

LIST OF TABLES

Table Page

1. Recommended Average vs. Average Vegetable, Fruit, Dairy, Grain, and Protein

Intake in 19-50-Year-Old Males and Females………………………………...…..6

2. Estimated Calorie Needs for Males Aged 17-30 Years’ Old……………………….9

3. Estimated Calorie Needs for Females Aged 17-30 Years’ Old ………………..…..9

4. Types of Preferred Treatment/Therapy for Anxiety……………………...……....16

5. Models of Comorbidity Relating Eating and Anxiety Disorders………………....21

6. Random Sample Questions from the 45-Itemized Stress Eating Survey……...…..30

7. Mean and Standard Deviation of Anxiety Score, Calories, Carbohydrates, Protein,

Fat, Sodium, and Sugar Intake in Undergraduate College Students (N=93)……...43

8. Pearson’s Correlation Matrix Results of Anxiety Score and Nutrient Intake in

Undergraduate College Students (n=93)……………………………………..…..44

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CHAPTER I

INTRODUCTION Anxiety is an abnormal and overwhelming sense of fear and apprehension coupled with the feeling of uneasiness and nervousness (Merriam-Webster Dictionary,

2019). There are four main types of anxiety that interrelate, and each type has different characteristics. The four different types are generalized anxiety disorder (GAD), panic disorder, social phobia disorder, and specific phobia disorder. When an individual is diagnosed with an anxiety disorder, the disorder is usually classified into one of the four types (United States Department of Agriculture, 2018). Anxiety displays a number of different physical symptoms including tension, sweating, increased pulse rate, trembling, dizziness, and rapid heartbeat (Kazdin, 2000). When an individual experiences anxiety and depressive symptoms, appetite becomes an issue. Anxiety is often linked to many other disorders such as bipolar disorders, eating disorders, and obesity. It goes hand in hand with diet especially in college students because anxiety has been shown to have some type of impact on dietary intake (Chen & Dilsaver, 1995; Feske et al., 2000; Simon et al., 2003; Strine et al., 2008).

There is a high prevalence of unhealthy diets consumed among college students

(American College Health Association, 2005). In one of the many studies conducted, 4% of the 2,489 college students surveyed reported eating 30% or less of energy from fat and

10% or less from sugar per day. It was also found that 78.4% of 18 to 24-year-olds reported consuming less than five servings of fruits and vegetables per day. Also, the

average daily fiber intake in this age group was sixteen grams which is less than the

recommended intake of 25-30 grams (American College Health Association, 2005).

Another study found that more than 80% of students surveyed consumed inadequate quantities of grains, fruits and vegetables, and dairy products (Haberman & Luffey,

1998).

College students have increased responsibilities, including financial, academic, and social stressors, which can deteriorate their mental health status (Dusselier, Dunn,

Wang, Shelley, & Whalen, 2005). A student’s mental health is important for quality of life. If college students know their relationship between food and anxiety, it might motivate them to be healthier. (American College Health Association [ACHA], 2008;

Beck & Clark, 1997; Dusselier et al., 2005).

It is essential to analyze food intake in students experiencing anxiety. Students who tend to consume more food when anxious are at an increased risk for developing diseases like obesity and diabetes (Willett & Stampfer, 1986). On the other hand, students who do not consume enough food when experiencing high levels of anxiety are at an increased risk of developing an eating disorder and/or becoming malnourished

(Hinrichsen, Wright, Waller, & Meyer, 2003). This can lead to additional medical issues that can further deteriorate their mental/physical health.

Statement of the Problem

College students tend to purchase food that is easy and quick to prepare. Most of the time, these types of foods are higher in fat, sugar, and sodium. It is important to research the relationship between anxiety levels and nutrient intake among college

students because this can help researchers better understand the importance of eating and sustaining a healthy lifestyle.

If students’ health care professionals do not know how their appetite responds to high levels of anxiety, this could lead to more college students developing disordered eating patterns (Hinrichsen et al., 2003). This is the time when college students are developing dietary habits for adulthood. If anxiety triggers them to either eat in huge amounts or not eat at all, this could have a long-term negative effect on their overall health (Hinrichsen et al., 2003). Major changes and events occur during a student’s college career. They are juggling school, work, having a personal life, keeping a job, and much more.

Anxiety in college students is an ongoing issue that can affect students in many different ways. It can affect their social life, mental health, and quality of life (Strine et al., 2008). Some students tend to get sick to their stomach during stressful/anxious times and forget to eat because their stomachs are upset. On the other hand, some students will indulge in food when stressed/anxious to try to alleviate the nervousness they are feeling

(Hinrichsen et al., 2003).

Determining if anxiety has more of a positive or negative effect on food consumption can potentially help college students in numerous ways. Colleges and universities can offer mental health classes, more nutritious food on campus, and include a mental health department at their health center to help their students. Looking at the relationship between anxiety levels and nutrient intake can be helpful in giving students access to the proper tools in order to receive the help they may need. Although multiple

studies have examined anxiety and food consumption, there needs to be more research

conducted that examines why college students’ diets do not meet their estimated needs and if it could possibly be related to their anxiety level (Beck & Clark, 1997; Kandiah,

Yake, Jones, & Meyer, 2006; Lykouras & Michopoulos, 2011).

Purpose Statement

The purpose of this correlational study was to evaluate if a relationship exists between anxiety scores and nutrient intake in undergraduate college students at a Midwestern

University.

Hypothesis

H1: There will be a relationship between anxiety scores and nutrient intake in undergraduate students at a Midwestern University.

H0: There will not be a relationship between anxiety scores and nutrient intake in undergraduate students at a Midwestern University.

Operational Definitions

Anxiety scores are defined as how anxious an individual is feeling within the past

2 weeks. It was measured using the GAD – 7 anxiety scale (Spitzer, Kroenke, Williams,

& Lowe, 2006).

Nutrient intake is defined as the number of calories (kcals), carbohydrates

(grams), protein (grams), fat (grams), sodium (milligrams), and sugar (grams) the individual consumed. It was measured using the online Automated Self-Administered 24- hour Dietary Recall System (National Cancer Institute, 2019).

Undergraduate students are defined as either freshmen, sophomores, juniors, or seniors in the process of completing an undergraduate degree from Kent State University.

CHAPTER II

REVIEW OF THE LITERATURE

Current Dietary Intake of Americans

The current dietary intake of Americans varies based on the type of foods the individual consumes. Most adults aged nineteen and older have low vegetable, fruit, and dairy intake but meet the recommended amounts for grains and proteins. The average daily intake by food group and recommended intake by gender in Americans is shown in

Table 1. The table compares the daily food intake by food group of males and females between the ages of 19-50 years old (United States Department of Agriculture, USDA,

2015). The current dietary intake of sugar is roughly 71 grams and the current sodium intake is around 3,400 milligrams (USDA, 2015). It is also shown that individuals from

19-30 years of age typically consume more solid fats and less fat from oils (USDA,

2015).

Table 1

Recommended Average vs. Average Vegetable, Fruit, Dairy, Grain, and Protein Intake in 19-50-Year-Old Males and Females

Food Group Recommended Average Daily Recommended Average Daily Average Daily Intake for Males Average Daily Intake for Females Intake for Males 19-50 years old Intake for Females 19-50 years old 19-50 years old 19-50 years old Vegetable 3-4 cups 1.75-2 cups 2.5-3 cups 1.5-1.75 cups

Fruit 2-2.5 cups 0.75-1 cup 1.5-2 cups 1 cup

Dairy 3 cups 1.5-1.75 cups 3 cups 1.25-1.5 cups

Grain 7-10 ounces 8 ounces 6-8 ounces 6 ounces

Protein 6-7 ounces 7-8 ounces 5-6 ounces 5.5 ounces (USDA, 2015)

Recommended Dietary Intake of Adults

Calories along with carbohydrates, fats, and protein have specific dietary intake recommendations. These recommendations vary based on different factors like age, weight, height, and physical activity level. (Westerterp, 2004; Willet & Stampfer, 1986;

USDA, 2015; American Heart Association, 2019). There are set dietary standards made by different organizations such as the USDA and the American Heart Association that give additional recommendations for each macronutrient: carbohydrate, protein, and fat.

Calories. According to the Willett and Stampfer (1986), there are many factors that need to be considered when calculating an individual’s caloric needs (Willett &

Stampfer, 1986). There are four general factors that play a part in this calculation, body size, physical activity, metabolic efficiency, and net energy balance. Willett and

Stampfer (1986) stated that height and weight are not needed to determine caloric intake.

In their study of four one-week weighed diet records produced over one year by 194 women aged 34-59 years, they found body size was not significantly correlated with caloric intake (Willett & Stampfer, 1986). They concluded that body size does not play a strong role in calculating caloric intake unlike physical activity. This article showed that there was a decrease in caloric intake in the U.S. while the prevalence of obesity increased (Willett & Stampfer, 1986). This is due to the fact that Americans are not as active as they need to be to sustain a healthy weight. Obesity in the U.S. is rapidly increasing due to fast food, convenient food, portion size, and lack of physical activity

(Willett & Stampfer, 1986).

Metabolic rate also plays a key role in caloric needs. An individual who is metabolically inefficient requires a greater amount of energy to maintain their level of activity and weight. A person’s metabolism is very individualized and needs to be considered when calculating their caloric needs. Differences in metabolism can contribute to factors like absorption and thermogenesis. According to Westerterp (2004), thermogenesis is an increase in energy expenditure above basal fasting level divided by the energy content of the ingested food. This can play a role in maintaining or developing obesity (Westerterp, 2004). Caloric intake is not enough to determine if a person will gain or lose weight. Calories alone do not provide a complete picture. Body size, metabolic efficiency, and physical activity need to be considered. As a result, two people eating the same diet may not put on or lose weight at the same rate due to metabolic efficiency. (Willett & Stampfer, 1986).

According to the USDA (2015), the estimated calorie needs of an individual differs based on their gender, age, and physical activity level. If there is a need to lose, gain, or maintain weight, that also must be considered as it impacts caloric needs. The estimates provided in Tables 2 and 3 are based on the Estimated Energy Requirements

(EER) using average heights and healthy reference weights for each sex-age group

(USDA, 2015). The references used to calculate caloric needs are five feet ten inches and

154 pounds for the average man and five feet four inches and 126 pounds for the average woman. Tables 2 and 3 show the average caloric recommendation for males and female ages 17 to 30 years old taking into consideration their physical activity levels (sedentary, moderately active, and active) (USDA, 2015). According to the Center for Disease

Control (2000), the average caloric intake for men of all ages is around 2,500 calorie s a day. For women of all ages, the actual average caloric intake is approximately 1,800 calories a day.

Table 2

Estimated Caloric Needs for Males Aged 17-30 Years’ Old

Age (years) Sedentary Moderately Active Active 17-18 2,400 2,800 3,200

19-20 2,600 2,800 3,000

21-25 2,400 2,800 3,200

26-30 2,400 2,600 3,000 (USDA, 2015)

Table 3

Estimated Caloric Needs for Females Aged 17-30 Years’ Old

Age (years) Sedentary Moderately Active Active 17-18 1,800 2,000 2,400

19-20 2,000 2,200 2,400

21-25 2,000 2,200 2,400

26-30 1,800 2,000 2,400 (USDA, 2015)

Carbohydrates. Carbohydrates are one of the three macronutrients and a primary source of energy. Carbohydrates include sugars, starches, and fiber (USDA,

2015). According to Clifford, Niebaum, and Bellows (2015), dietary fiber comes from the part of the plant that is not digested in the gastrointestinal tract. There are two types of fiber, soluble and insoluble fiber. The soluble fiber is water-soluble and is found inside plant cells. Soluble fiber does not increase fecal bulk but does slow down food when going through the intestines. Insoluble fiber is water insoluble. This type of fiber

increases fecal bulk and helps speed up the process of food going through the intestines

(Clifford, Niebaum, & Bellows, 2015). There are many different foods containing starches like vegetables, legumes, and grains. Sugars are formed by either glucose, fructose, lactose, or sucrose (USDA, 2015). Sugars naturally occur in foods and beverages, are added to foods and beverages during processing and preparation, or are consumed separately (USDA, 2015).

According to the USDA (2015), the recommended dietary intake for carbohydrates is 130 grams per day. This accounts for the age range from 1-51 years old and older for males and females. The acceptable macronutrient distribution range

(AMDR) for carbohydrate is 45-65% of total calories per day irrespective of gender or age.

Fats. According to the American Heart Association (2019), there are four different types of fat: saturated, trans, monounsaturated, and polyunsaturated. Saturated and trans fats should be limited in the diet while the monounsaturated and polyunsaturated fats should be consumed in moderation within the AMDR’s for fat. The

AMDR for fats are 20-35% of total dietary calories in individuals who are 19 years and older. (USDA, 2015). There are nine calories/gram of fat regardless of the type of fat

(American Heart Association, 2019). Only five to six percent of daily calories should be coming from saturated fat. Trans fats are to be consumed less than saturated fats are or eliminated from the diet completely. A large majority of the fats that an individual consumes should come from monounsaturated and polyunsaturated fats (American Heart

Association, 2019).

In the United States, the main food source of saturated fat comes from cheese and meat (USDA, 2015). Examples of foods high in saturated fats include burgers, sandwiches, tacos, pizza, pasta, meat, poultry, seafood, sweets, and dairy products. The current average intake of saturated fat is roughly 11 percent of the total calories an individual consumes, which is nearly double what is recommended (USDA, 2015). The

USDA has goals in place to try to overcome some of the unhealthy dietary habits within the U.S. population. One goal of the USDA is to reduce saturated fat intake to less than ten percent of total daily calories (USDA, 2015).

The high intake of saturated fats is causing numerous health issues in the United

States including heart disease. There are many suggestions for reducing saturated fat intake in the diet; they include using fat-free milk instead of two percent or whole milk, consuming low-fat cheese, and consuming leaner cuts of meat. Another recommendation is to consider portion size. Reducing portion size can have a huge effect on the amount of saturated fat an individual consumes daily (USDA, 2015). Another option is to cook using more polyunsaturated and monounsaturated fats by using oil instead of butter, using oil-based dressings, and oil-based spreads (USDA, 2015). Small changes such as cooking with oil instead of butter may positively impact the nation’s overall health.

Protein. Protein comes from both animal and plant sources and includes several subgroups: seafood, meats, poultry, eggs, nuts, seeds, and legumes. Protein contains many important nutrients such as B vitamins, selenium, zinc, copper, vitamin D, choline, and vitamin E. Different protein sources contain different types of nutrients. Meats tend to provide the most zinc and iron while poultry provides a high amount of niacin.

According to Iron We Consume (2009), heme iron is easily absorbed into the body and is the best source of iron for someone who is deficient. Beans and legumes are a great source of protein and can be added to many dishes to increase the protein content of a meal. Seafood provides an excellent amount of Vitamin B12 and Vitamin D. Eggs have the most choline while nuts and seeds provide the most Vitamin E (USDA, 2015).

Protein is one of the macronutrients that improves overall health in multiple ways by supplying the body with many different vitamins and minerals.

According to Fulgoni (2008), protein intake, like fat can be measured multiple ways. It can be measured by using the dietary recommended intake (DRI) of 0.8 grams/kilogram of body weight or by using the AMDR of 10-35% of total calories.

Calculating protein intake is very specific to the individual person. According to the

USDA (2015), an individual on a 2,000-calorie diet should consume roughly five and a half ounces of protein per day. This varies greatly depending on the individual’s sex, weight, height, and physical activity level (Fulgoni, 2008).

Anxiety

Anxiety is a normal response to stress, and is a feeling of worry, nervousness, or fear about a situation that is going on in an individual’s life (Digital Communications

Division, 2015). According to Strine et al. (2008), depression and anxiety are related to mortality and morbidity in the United States. Anxiety and depression are commonly linked together because they both are associated with quality of life. Depression and anxiety can often be treated with medication, but most people do not seek the help they need. Individuals with anxiety disorders usually have recurring damaging thoughts and

concerns so they try to avoid specific situations out of worry (Kazdin, 2000).

Anxiety can be disabling and debilitating because it interferes with everyday activities like going to work, going to the store, or driving in a car. Anxiety can manifest into an anxiety disorder when it begins to interfere with daily life. Anxiety disorders are twice as common in women compared to men (Digital Communications Division, 2015).

There are four main types of anxiety disorders: generalized anxiety disorder (GAD), panic disorder, social phobia disorder, and specific phobia disorder.

Generalized Anxiety Disorder (GAD)

According to the Anxiety and Depression Association of America (ADAA) (2018), general anxiety disorder (GAD) is distinguished by persistent and excessive worry about different items that sometimes are uncontrollable. GAD occurs with people who worry excessively about daily living factors like health, money, work, and family. An individual with GAD tends to have a racing mind and is quick to jump to conclusions.

This disorder affects 3.1% of the U.S. population each year (ADAA, 2018). Some symptoms of GAD include tense muscles, difficulty sleeping, and an upset stomach

(Digital Communications Division, 2015). One treatment for GAD is cognitive behavioral treatment (CBT). This form of therapy targets thoughts, physical symptoms, and behaviors that an individual has when diagnosed with a GAD. Another form of treatment is medication. There are many different anxiety medicines that can be used to help treat this disorder, but the Selective Serotonin Reuptake Inhibitors (SSRIs) usually work the best. SSRIs include medicines like Celexa, Lexapro, Prozac, Paxil, Zoloft, and

Viibryd (ADAA, 2018).

Panic Disorder

A panic disorder occurs when an individual has an unexpected attack of terror when there is no actual danger. Sometimes they believe they are having a heart attack or even dying (Digital Communications Division, 2015). According to the ADAA (2018), a panic disorder is diagnosed in individuals who experience out of the blue panic attacks and are very nervous and afraid of a recurring attack. Panic attacks come about unexpectedly even when waking from sleep. Roughly two to three percent of Americans experience a panic disorder every year. This disorder can interfere with daily living causing individuals to miss work, have many doctor appointments, and avoid situations that make them feel anxious (ADAA, 2018).

Social Phobia Disorder

Social phobia disorder, also referred to as social anxiety disorder, occurs when an individual becomes very anxious and self-conscious about social gatherings and situations. Individuals with social phobia disorder feel they are being watched or judged by others and are scared of embarrassment (Digital Communications Division, 2015).

According to the ADAA (2018), individuals with social phobia disorder worry about being visibly anxious in front of others, or being viewed as awkward, unintelligent, and boring. As a result, they avoid social type of situations. Some symptoms of social phobia disorder include rapid heart rate, nausea, and sweating. This disorder affects roughly 15 million American adults each year. Individuals with this disorder will usually suffer for roughly ten years before seeking the help they need.

Specific Phobia Disorder

Specific phobia disorder is a fear of something that does not cause any danger .

Examples include fear of closed spaces, heights, water, germs, insects, or animals.

Individuals with this disorder tend to have severe anxiety when thinking about coming face to face with the object they are scared of (Digital Communications Division, 2015).

According to the ADAA (2018), individuals with this disorder tend to avoid common places, situations, or objects even though they know there is no threat or danger. Having specific phobias can interfere with daily routines, limit work efficiency, reduce self- esteem, and cause issues in relationships (ADAA, 2018).

Anxiety Treatments

According to Kessler et al. (2001), there are many different treatment options for anxiety that do not require taking a pharmacologic medicine. There are different ways to cope using herbals remedies, physical treatment, and folk remedies. The four types of treatment and their subtypes are found in Table 4.

On the other hand, according to the National Institute of Health (NIH) (2018), anxiety disorders are treated by two therapies: psychotherapy and/or medication.

Psychotherapy helps treat anxiety when it is tailored to that specific person’s anxieties and addresses that individual’s needs. Cognitive Behavior Therapy (CBT) is one type of commonly used psychotherapy. There are two subtypes of CBT, cognitive and exposure therapy. According to the NIH (2018), these two methods are usually used together or by themselves in order to treat a social anxiety disorder. Cognitive therapy is designed to identify, challenge, and then neutralize distorted thoughts while exposure therapy focuses

on confronting the individuals’ fears to help them engage in activities they have been avoiding. Often times, exposure therapy is used alongside relaxation exercises (National

Institute of Health, 2018).

Table 4

Types of Preferred Treatment/Therapy for Anxiety

Type of Treatment Examples (subtypes)

Cognitive • Relaxation Feedback Techniques • Imagery • Hypnosis

Oral Medication • Herbal Medication • Megavitamins • Homeotherapy • Naturopathy

Physical • Massage Treatments • Osteopathy • Acupuncture • Yoga

Other types • Dietary Modifications • Lifestyle Diet • Aromatherapy • Folk Remedies • Energy healing

(Kessler et al., 2001)

There are many different types of anti-anxiety medications that individuals use to help relieve symptoms. This medicine can be prescribed by a primary care provider or a psychiatrist. The dosage depends on the anxiety type and severity the individual is

experiencing. A few common anti-anxiety medications include benzodiazepines, antidepressants, and beta-blockers (NIH, 2018).

Anxiety and Depression

According to Fava et al. (2000), major depressive disorder (MDD) in children and adults is associated with anxiety disorders. Anxiety symptoms are likely to occur during depressive episodes even if the individual is not diagnosed with an anxiety disorder.

Depressive disorders occur more frequently when the individual also has a diagnosis for an anxiety disorder (Fava et al., 2000). According to Hirschfield (2001), 10–20% of adults in any given twelve-month period will visit their primary care physician during an episode of mental illness (Hirschfield, 2001). When dealing with anxiety and depression, the individual’s quality of life plays an important role.

In their study on the relationship between anxiety disorders and quality of life,

Rapaport, Clary, Fayyad, and Endicott (2005) found, “[…] subjects with psychiatric disorders relative to normative comparison subjects had diminished quality of life across all of the domains measured by the Quality of Life Enjoyment and Satisfaction

Questionnaire” (p. 1173). Quality of life is very important when dealing with individuals who suffer from mental illness. Having a low quality of life means that the will to live is in decline. When this happens, options like cutting, burning, and committing suicide are likely to be considered by mentally ill individuals (Rapaport et al., 2005). According to the Diagnostic and Statistical Manual of Mental Disorder (DSM5; 2017), individuals who experience anxiety and depression have a higher likelihood of committing suicide.

Mental illness is a serious issue that needs to be addressed. The first step would be

looking at ways to treat these depression and anxiety disorders. Then, deal with any other disorders they may suffer from.

According to Strohle (2008), physical activity and exercise positively affect mood which helps to reduce anxiety levels. Strohle (2008) asserted that physical activity is an effective treatment for depression and anxiety disorders. Strohle also believed that medication can be used to reduce the amount of stress an individual is experiencing.

According to Peterson and Pbert (1992), a mindfulness meditation program can effectively reduce symptoms of panic or anxiety for those suffering from anxiety and depression.

Anxiety and Bipolar Disorder

According to Naomi Simon (2003), anxiety disorders develop early in life and frequently before the first episode of a major depression disorder. When an individual is first diagnosed with generalized anxiety disorder, they are likely to develop a major depressive episode within that same year (Simon, 2003). Bipolar disorder is linked with low quality of life scores similar to depression disorders (Kauer - Sant’Anna et al., 2007).

It is also found that quality of life is impaired during mood fluctuation episodes. Overall, bipolar disorders show higher scores for depression and lower scores for quality of life.

Many patients with a bipolar disorder also complain of anxiety. In the national comorbidity survey, 92.9% of the subjects who met the criteria for lifetime bipolar disorder also met the criteria for lifetime anxiety disorder (Kauer - Sant’Anna et al.,

2007).

Recent studies have concluded that bipolar disorder and unipolar depressive disorder may be related to anxiety disorders (Simon et al., 2003; Taylor et al., 2007 ).

Panic disorder and generalized anxiety disorder tend to be more prevalent in patients diagnosed with bipolar disorder. Over half of all patients with bipolar disorders (51.2%) also had a co-occurring anxiety disorder at some point in their life (Simon et al., 2003).

Individuals experiencing these disorders are more likely develop more severe mental health issues. which can eventually lead to bad decisions. In patients with a bipolar disorder, impulsivity is associated with negative outcomes including suicide and substance abuse (Taylor et al., 2007).

Chen and Dilsaver (1995) found that individuals with bipolar disorder were more likely to have panic attacks and obsessive-compulsive disorders than individuals without bipolar disorder. Patients with bipolar disorder, in addition to experiencing high levels of anxiety symptoms, are more likely to exhibit suicidal behavior, alcohol abuse, and cyclothymia. They are more likely to require treatment with antidepressants or neuroleptics in addition to lithium (Chen & Dilsaver, 1995). Individuals with bipolar disorder and anxiety issues are more likely to be mentally unstable. More research is needed on the relationship between anxiety and bipolar disorder (Feske et al., 2000).

Anxiety and Eating Disorders

According to Fairburn and Brownwell (2005), “the earliest clinical descriptions of anorexia nervosa and bulimia nervosa noted the frequent presence of both depression and anxiety” (p.193). Table 5 below presents five of the models used to explain the relationship between eating and anxiety disorders.

According to Mitchell, Pyle, Hatsukami, & Eckert (1986), there are five criteria when diagnosing an eating disorder: anorexia nervosa, bulimia nervosa, atypical eating disorder, pica, and rumination disorder of infancy. These disorders commonly appear during childhood and adolescence (Mitchell et al., 1986). Eating disorders are a serious issue and can increase anxiety and suicide risk (DSM 5, 2017).

In more recent literature, there are still five criteria that deal with feeding and eating disorders (DSM5, 2017). The first criteria is pica. An individual is diagnosed with pica after a persistent eating of nonnutritive substances over a period of one month.

Pica is related to anxiety issues because it occurs with other disorders associated with impaired social functioning. Most disorders that deal with social functioning have some type of relation to anxiety and depression. The second criteria is rumination disorder, the repeated regurgitation of food over a period of one month. This disorder is caused by psychological problems such as lack of stimulation, neglect, or stressful life situations and can lead to anxiety and depression problems.

The third criteria is avoidant/restrictive food intake disorder, which is characterized by an eating or feeding disturbance that results in unmet nutritional or energy needs. It is associated with significant weight loss, significant nutritional deficiency, and dependence on enteral feedings. Avoidant/restrictive food intake disorder is closely related to mental health issues as its risk factors include anxiety disorders, obsessive-compulsive disorder, attention deficit disorder, and unusual eating behaviors.

This disorder often leads to malnutrition, low body weight, and growth delays.

Avoidant/restrictive food intake disorder is often diagnosed with other disorders as well,

including anorexia nervosa and major depressive disorder.

Table 5

Models of Comorbidity Relating Eating and Anxiety Disorders

Model Relationship between Eating and Anxiety Model 1 Eating disorders are a result of depression and anxiety. This model predicts that when depression and anxiety are alleviated, it will help the individual recover from the eating disorder.

Model 2 This model predicts that an individual will most likely suffer from depression and anxiety and that will lead to the onset of an eating disorder.

Model 3 This model states that eating disorders are an expression of an underlying anxiety or depressive disorder. Eating disorders can be age and gender related but are exhibited when the individual is experiencing anxiety or depression symptoms.

Model 4 This model claims that eating, anxiety, and depressive disorders are different expressions of the same underlying factor (a hormonal imbalance).

Model 5 This model claims that there are differences between eating disorders, anxiety disorders, and depressive disorders but these disorders do share some of the same etiological factors. (Fairburn & Brownwell, 2005)

Anorexia nervosa is characterized by a restriction of energy intake which leads to a very unhealthy, low body weight. There are two different types of anorexia nervosa.

The first is binge-purge where individuals binge eat large amounts of food then either throw up the food, use laxatives, diuretics, or enemas. The second type is when an individual only eats small amounts of food. There has been seen to be crossover between these subtypes and that is actually quite common. Individuals who are more at risk for developing anorexia nervosa usually have anxiety disorders (DSM 5, 2017). Suicide risk is very high in individuals diagnosed with anorexia nervosa. Anorexia nervosa takes a major toll on an individual’s mental health.

The fifth and final criteria in the DSM 5 (2017), is bulimia nervosa, which is

diagnosed when an individual has recurrent episodes of binge eating. Individuals with bulimia nervosa have many episodes of binge eating and will usually vomit to avoid weight gain. The difference between bulimia nervosa and anorexia nervosa are that individuals with bulimia tend to maintain their body weight at or above a normal level while individuals with anorexia nervosa lose weight and become very malnourished

(DSM 5, 2017).

According to Hinrichsen et al. (2003), social anxiety and eating disorders are heavily related. Their study found a much higher proportion of the eating-disordered groups have high social anxiety scores with the highest level of anxiety occurring in the binge-purge type (Hinrichsen et al., 2003). More research is needed to determine if social anxiety is the main contributor for eating disorders or if there are other factors at play.

Anxiety and Obesity

According to Zwaan (2001), obesity is an excess amount of bodyweight and is the biggest contributor to an individual developing any type of disease. Anxiety disorders are very frequent, mental disorders in developed countries while obesity is one of the biggest health problems in the U.S. (Lykouras & Michopoulos, 2011). The connection between body weight and mental disorders is an ongoing issue. The prevalence of high body weight relating to anxiety still does not have enough supportive evidence to be justified. It has been known that obesity is somewhat related to depression and anxiety because some studies show a positive relationship in women with panic disorders

(specific or social phobia) and obesity. (Lykouras & Michopoulos, 2011).

According to Zwaan (2001), obesity can be related to an eating disorder known as binge eating disorder (BED). BED is characterized by recurrent episodes of binge eating in which the individual will feel uncomfortably full, eat when not physically hungry, and eat alone when feeling depressed or guilty. BED is most common in obese individuals.

In many cases, the individual will seek help for obesity not for the root of the issue, the binge eating disorder (Zwaan, 2001). If an obese individual is receiving help to lose weight, treatment is needed for both the weight loss and the eating disorder. Treating the eating disorder first helps ensure a more stable and sustained weight loss (Zwaan, 2001).

There are medications to treat obesity that can lead to high levels of anxiety and depression making it difficult to determine if the anxiety stems from the obesity or the medication (Lykouras & Michopoulos, 2011). One type of medication that interferes with anxiety and depression is the drug rimonabant (Lykouras & Michopoulos, 2011).

According to Moreira and Crippa (2009), specific drugs that enhance cannabinoid type-1

(CB1) receptor activity may cause anti-anxiety and anti-depressive side effects. CB1 is the most abundant G-protein-coupled receptor found in the central nervous system.

Rimonabant is the antagonist of the CB1 receptor in that it can cause anxiety and depressive symptoms. Individuals taking rimonabant are at risk of experiencing anxiety and depressive symptoms while on the medication (Moreria & Crippa, 2009).

Gariepy, Nitka, and Schmitz (2009) found that obesity may be a risk factor for anxiety disorders for a number of reasons. The first is that when an individual is obese, they tend to get bullied, which can lead to depression. Second, their quality of life is significantly decreased because they cannot perform functions that the average person

can. Both of these reasons can result in anxiety and depression (Gariepy et al., 2009 ).

There is currently no evidence linking obesity and anxiety disorders; some studies have found an association between these two conditions while other studies have found no significant relationship (Gariepy et al., 2009). The severity of anxiety can change based on a number of factors including gender. Obese women tend to be bullied more for their weight than men which could lead to women having more anxiety and depression than men (Gariepy et al., 2009).

College Students and Anxiety

According to Mahmoud et al., (2012) roughly 40 million individuals suffer from anxiety, with 75% of them having experienced their first anxiety episode by the age of

22. This is when most individuals are attending college. From 2000 to 2006, the rate of diagnosis for college students with depression increased five percent. The second leading cause of death for college students is suicide related to depression and anxiety (American

College Health Association [ACHA], 2008). According to Lepp, Barkley, and Karpinski

(2013), cell phone use/texting in college students has caused many students to be diagnosed with some type of mental illness. Their study found that cell phone/texting was negatively related to GPA and positively related to anxiety. Because of this, GPA was positively related to satisfaction with life (SWL) and anxiety was negatively related to SWL. This means that cell phones are causing mental health issues and lowering the quality of life in individuals (Lepp, Barkely, & Karpinski, 2013). Cell phone usage is becoming more prevalent, especially with younger individuals, so this could potentially lead to mental health issues starting at a younger age.

According to Dusselier et al. (2005), college undergraduates have to deal with financial, academic, and social stressors which can challenge their mental health.

College tends to a stressful time for many students. There are many different ways that college students begin to cope with these stressors. According to Beck and Clark (1997),

“Depression and anxiety are not directly caused by stressors; rather, it is a state that results from an individual’s perception and reaction to those stressors” (p. 53). If students are able to react differently to these stressors, they might not experience such high levels of depression and anxiety. If they cannot cope with these stressors, they might choose to use illegal drugs, alcohol, prescription medication, etc. to manage their stress. How they choose to handle these responsibilities and cope with them is where mental health plays a huge role. This is why it is very important that college students dealing with mental illness receive the proper help they need.

According to the research conducted by Beiter et al. (2015), there has been an increase in the percent of college students visiting the counseling centers that their university provides. According to Beiter at al.’s study, the top three concerns for college students were academic performance, pressure to succeed, and post-graduation plans.

The students found to be the most stressed, anxious, and depressed students were transfer students, upperclassmen, and students who did not live on campus (Beiter et al., 2015).

These students may be under more stress because they are unfamiliar with the local area, find their classes increasingly more challenging, and money is an issue. To better understand student stressors and determine effective responses, colleges could benefit from surveying their students to evaluate their mental health. They could then create

treatment programs to help target their needs. Colleges and universities should offer specific classes for students who need guidance on relaxation and self-care techniques .

Several studies have shown that stress can have a significant impact on appetite

(Kandiah et al., 2006). According to their study, Kandiah et al. found that fat and sweet food consumption increased under high amounts of stress (2006). Their study also noted that from 2001 to 2004, 59% of their sample of 275 college students experienced some type of anxiety (Kandiah et al., 2006). Studies like these reinforce the need for research on college students and the impacts of anxiety on their eating habits.

College Students and Dietary Intake

The Journal of American College Health (2012) reported that between 51% and

72% of weight gain in female college students occurred during their freshmen year. This pattern is often referred to as the “freshmen 15.” Women tend to gain more weight during their first year in college than males. This study showed that the average weight gain was between 4.6 to 7.4 pounds (Journal of American College Health, 2012).

Though less than 15 pounds, this weight gain is significant in that women may continue to gain weight at that rate over their college career. This could result in women becoming overweight or obese and put them at risk for many health issues related to obesity (Journal of American College Health, 2012).

A second study on college weight gain showed that of 214 subjects, 135 students (82 females and 53 males) gained weight during their first year of college. The average weight gain for the group was 6.0 ± 5.3 pounds and there was no significant difference found between males and females (Journal of American College Health, 2010). This

same study found that roughly 60% of the weight gained was in body fat. Weight gain is a problem for most college students during their freshmen year, especially their first semester. Almost two thirds of freshmen gained weight their first year of college, with only five percent of these students gaining the “freshman 15.” It can be concluded that the “freshman 15” may be a myth but that there is still significant weight gain (Journal of

American College Health, 2010).

Another article by the Journal of American College Health (2010) revealed a high prevalence of unhealthy diets among college students. In one of the experiments conducted during this study, only 4% of the 2,489 participants reported eating 30% or less of energy from fat and 10% or less from sugar per day. This study also found that

78.4% of 18 to 24-year-olds reported consuming less than the five recommended servings of fruits and vegetables per day. The average daily fiber intake in this age group was sixteen grams (Journal of American College Health, 2010). The recommended amount of fiber to consume in a day is 25 grams for females and 38 grams for males (USDA, 2018).

According to another study that was conducted, more than 80% of the students reported consuming inadequate quantities of grains, fruits and vegetables, and dairy products

(Haberman & Luffey, 1998). Overall, the research suggests that college students tend to choose foods that are not nutritious for their body. They tend to consume foods that are high in sugar and fat which are likely to cause them to gain weight and may lead to other health complications.

Types of Food and Amount Consumed When Experiencing Anxiety

Research has found a link between emotions and food consumption (Canetti,

Bachar, & Berry, 2002). Macht and Simmons (2000) found that the relationship between a particular emotion and eating behavior is stronger when that emotion occurs more frequently than other emotions. Lyman (1982) found that food consumption increased during periods of boredom, depression, and fatigue while food consumption was lower during periods of fear, tension, and pain. In addition, Lyman found a greater tendency to consume healthy foods during positive emotions and a greater tendency to consume junk food during negative emotions (1982).

Research conducted by Patel and Schlundt (2001) found that meals eaten when in a positive or negative mood are larger in size than meals eaten in a neutral mood, with a positive mood having a stronger impact than a negative mood on food intake. Research by Macht (1999) noted the different impacts of anger, fear, sadness, and joy on food consumption. High levels of hunger were observed in subjects when they experienced anger and joy in contrast to lower levels of hunger when they experienced fear and sadness. This study also reported an increase in impulsive eating during anger directed at any food type available. During moments of joy, there was an increase in the tendency to eat because of the taste or health of the food (Macht, 1999).

According to the research of Kandiah et al. (2005), when an individual is stressed, the amount and type of food they want to consume differs based on sex, age, gender, stressor, and restraint level. Further, food consumption differs depending on whether the individual is turning to food for psychological comfort or physiological need (Kandiah et al., 2005). The research suggested that fat and sweet consumption increases under stress, with males preferring warm hearty comfort food and females preferring snack related

food like chocolate and ice cream (Kandiah et al., 2005).

The study conducted by Kandiah et al. (2005) looked at 272 female college women between the ages of 17-26 years old. These women were asked about their age, sex, grade classification, college credit hours taken, living situation, marital status, employment status, and whether they had any children. In addition, the participants completed a 45-itemized stress eating survey. The sample questions asked in the survey are found in Table 6. The study found 81% of women reporting a change in appetite when stressed, with 63% reporting an increase in their appetite (Kandiah et al., 2005).

Research conducted by Canetti et al. (2002), found that for normal weight subjects, stress decreased eating for those who were hungry and had no effect on those who were not hungry. However, overweight subjects ate the same amount of food regardless of their physiological state. Ganley (1989) found that obese individuals seeking psychological treatment tended to eat based on their emotions.

Emotional eating does not occur on a regular basis. It is associated with different emotions in different individuals. Emotional eating is when a person consumes high calorie or high carbohydrate food as a result of their emotional state. Emotional eating occurs most often when individuals are alone and at home. Interestingly, Ganley’s study found that a positive mood can increase food intake. According to this study (Ganley,

1989), subjects of normal weight had a decreased appetite when stressed while overweight individuals did not. When in a positive mood, individuals tend to consume more food as well (Ganley, 1989).

Table 6

Random Sample Questions from the 45-Itemized Stress Eating Survey in Female College

Women ages 17-26 Years’ Old

Survey Sections Subsections Sample Question PI None What is your classification in school? a. Freshman b. Sophomore c. Junior d. Senior e. Graduate Student

CD Family Family: Poor health or death of a family member or close Social friend (indicate the amount of distress it currently causes Individual you). Environmental a. None Work b. Somewhat College c. Moderate d. Extreme

EH None How much effort do you put forth to control your eating? a. Great effort (eg, limit energy intake, narrow range of food choices) b. Considerable effort (eg, read food labels, sometimes limit food intake) c. Some effort (eg, select low-fat or low-sodium foods) d. Little or no effort

FENUS Mixed dishes Mixed dishes (check all that apply): Salty/crunchy foods a. Burgers or sandwich meat items (eg, steak, Sweet foods chicken) Creamy foods b. Pizza Beverages c. Casseroles (eg, lasagna) d. Tacos e. Ethnic foods (eg, Chinese, Mexican, Thai food) f. Fast food/restaurants g. Other ______

FEUS Mixed dishes Mixed dishes (check all that apply): Salty/crunchy foods a. Burgers or sandwich meat items (eg, steak, Sweet foods chicken) Creamy foods b. Pizza Beverages c. Casseroles (eg, lasagna) d. Tacos e. Ethnic foods (eg, Chinese, Mexican, Thai food) f. Fast food/restaurants g. Other ______

(Kandiah, Yake, Jones, & Meyer, 2005)

CHAPTER III

METHODOLOGY

Overview

This correlational study evaluated the relationship between anxiety scores and nutrient intake in college students at a Midwestern University. It was hypothesized that there will be a relationship between anxiety scores and nutrient intake in undergraduate students at a Midwestern University. The variables in this study were anxiety scores and calories (kcals), carbohydrates (grams), protein (grams), fat (grams), sodium

(milligrams), and sugar (grams). This research was approved by the Institutional Review

Board (IRB) at Kent State University (Appendix A).

Participants

The sample consisted of undergraduate college students between the ages of 18-

24 years old at Kent State University. Students were excluded from the study if they had a medical diagnosis for an anxiety disorder. This study was not limited to a specific gender and all ethnicities were included in this study. The participants in the study came from multiple living situations which included having a roommate, living with a significant other, living alone, and living on or off campus. The participants were all students attending Kent State University’s Main Campus.

Survey Components

Data was collected using an electronic survey. The first part of the survey consisted of demographic questions. The second part of the survey was the Generalized

Anxiety Disorder (GAD)-7 anxiety scale (Spitzer, Kroenke, Williams, & Lowe, 2006).

The students ranked their level of anxiety in the past two weeks using the scale. Once that was complete, there was an option to continue to part III of the survey, the diet analysis portion of the survey.

Parts I and II of the survey were e-mailed using the Qualtrics system, an online survey program that is available to the public. Part III of the survey was completed using the Automated Self-Administered (ASA) 24-hour dietary recall tool.

Part I: Demographics. Part I of the survey asked ten demographic questions

(Appendix B). The first four questions regarding age, birthdate, class, and medical diagnoses were used to determine if participants met eligibility criteria. Students who reported that they were minors or older than 24, were graduate students or above, and had been diagnosed with an anxiety disorder, were not included in the study. The next three questions asked regarded sex, ethnicity, and living status. The eighth question asked if they had ever experienced any type of anxiety. They were then asked if they tended to eat more or less during these anxious times. If they ate more, they were asked to list the types of food they ate. If they ate less, they were asked why. Once participants responded to the demographic questions, they were taken to part II of the survey.

Part II: GAD -7 anxiety scale. The GAD -7 anxiety scale consisted of seven questions (Appendix B). These questions asked, “over the past two weeks, how long have you been bothered by the following problems?” The individual ranked their answers to each question by either selecting “not at all sure,” “several days,” “over half the days,” or “nearly every day.” Each one of the responses corresponded to a number from zero to three. Zero being the “not at all response” and three being the “nearly every

day” response. At the bottom of the scale, the scores were added up for each column.

Individual scores were tabulated; the highest score is 21. This anxiety scale measured their level of anxiety over the past two weeks.

Part III: 24-hour dietary recall. The third and final part of the data collection element asked participants to log their diet using the Automated Self-Administered 24- hour Dietary Assessment Tool (National Cancer Institute, 2019). After they completed the GAD-7 anxiety scale, they had the option of continuing to part III of the survey. In order for the students to log their diet, they needed a username and password for the website. The website generated usernames and passwords for the students once the researcher logs how many participants were willing to participate. In order for this to be accomplished, the original e-mail with part I and II of the survey asked for continuation to part III of the survey. To continue to part III of the survey, the student had to reply to the researcher and state their birthdate and inquire that they wanted to continue to part III.

The researcher then generated usernames and passwords for the students that replied.

The target goal for the number of full responses to part III of the survey was fifty students.

The ASA 24-hour dietary Assessment tool is a tool used to track meals from the previous day. This is a computer program that generates the number of calories (kcals), carbohydrates (grams), protein (grams), fat (grams), sodium (milligrams) and sugar

(grams) consumed based on the 24-hour log that was entered into the program. This tool used portion size and asked very specific questions regarding the type of food item that was consumed in order to better analyze the specific number of calories (kcals),

carbohydrates (grams), protein (grams), fat (grams), sodium (milligrams) and sugar

(grams) the individual consumed for that food item.

Data Collection Procedures

After IRB approval, the students from Kent State University’s main campus were emailed and invited to participate in the study (Appendix C). They received information about the study, its components and aims, and their rights as study participants. They received a letter of consent (Appendix D) which they were required to complete before they could participate in the study. Emails were obtained through the registrar. To increase participation and completion rates, a $10 amazon gift card was awarded to the first 10 students who completed all survey elements. All participants were given two weeks to complete all three parts: the survey, anxiety scale, and dietary recall.

The survey was accessible through any device with internet access. Once the students had responded to the survey, their responses were collected through the

Qualtrics system. In order for the students to complete part III of the survey, they were required to e-mail the researcher and say they wanted to participate in part III. The ASA

24-hour dietary assessment tool requires a username and password for every individual that uses its software. The usernames and passwords were e-mailed to the student, along with the link to the dietary assessment tool, in order to continue with part III. The students then had to log into the website and then record their diet. Survey results, emails, and birthday information were maintained confidential.

Once the individual logged into the ASA 24-hour dietary assessment tool, a short introductory tutorial explained how to use the tool. The students could click the “next”

button if they understood how to use it. The tool asked what meal the individual wanted to log, the time they ate it, where they ate it, if they were watching tv or on a tablet/phone/computer, and who, if anyone they ate with. After answering those questions, the students then searched for the type of food they ate and added it to their recall. After they finished the dietary recall, they were asked where they purchased the food they ate, how it was prepared, and the amount they consumed. They were asked reminder questions to make sure they did not forget any foods, snacks, or drinks.

Participants had access to the caloric intake by meals, daily food group targets, and the nutrients intake report.

Data Analysis Procedures

All data was analyzed using Statistical Package for Social Sciences (SPSS) version XII. Descriptive statistics, including means and standard deviations, were used to analyze participant demographics. The GAD – 7 anxiety scale was analyzed by generating a number for the individual that corresponded with their anxiety level. The range for the GAD-7 anxiety scale is 0-21, with 21 representing the highest level of anxiety. The nutrient intake variables from the 24-hour dietary recall included the number of calories, grams of carbohydrates, grams of protein, grams of fat, milligrams of sodium, and grams of added sugars. Pearson’s correlation was used to find the relationship between anxiety scores and nutrient intake by using the coefficient, r. The study showed a significant relationship between anxiety score and nutrient intake (r-.207, p=.046).

CHAPTER IV

JOURNAL ARTICLE

Introduction

Anxiety is defined as an abnormal and overwhelming sense of fear and apprehension coupled with the feeling of uneasiness and nervousness (Merriam-Webster

Dictionary, 2019). There are four main types of anxiety; Generalized Anxiety Disorder

(GAD), panic disorder, social phobia disorder, and specific phobia disorder (Digital

Communications Division, 2015). Each of these types have their own specific symptoms and characteristics. Once an individual is diagnosed with an anxiety disorder, it is usually classified into one of the four types in order to be treated appropriately (Digital

Communications Division, 2015). Anxiety displays a number of different physical symptoms like tension, sweating, increased pulse rate, trembling, dizziness or rapid heartbeat (Kazdin, 2000). According to the American College Health Association (2005), it has been found that roughly 63% of college students in the U.S. experiencing a feeling of overwhelming anxiety.

College students have increased responsibilities including financial, academic, and social stressors, which can deteriorate their mental health status (Dusselier, Dunn,

Wang, Shelley, & Whalen, 2005). This can impact the individual’s quality of life. Often times, it can be hard juggling a personal life, keeping a job, completing schoolwork, and much more. During stressful/anxious times, students may forget to eat because they are sick to their stomach or may overindulge to try to alleviate the stress (Hinrichsen, Wright,

Waller, Meyer, 2003).

A high prevalence of unhealthy diets are consumed by college students. They tend to receive most of their calories from fat and sugar and also have a decreased intake of fruits and vegetables (USDA, 2015). It was shown that roughly 80% of college students consume an inadequate amount of grains, fruits and vegetables, and dairy products (Haberman & Luffey, 1998). Research shows that college students’ typical eating habits do not meet their recommended needs.

It is essential to analyze food intake in students experiencing anxiety because those who tend to consume more food when stressed are at an increased risk for developing diseases like obesity and diabetes (Willett & Stampfer, 1986). On the other hand, students that do not consume enough food when experiencing high levels of anxiety are at an increased risk for developing an eating disorder and possibly becoming malnourished (Hinrichsen, Wright, Waller, & Meyer, 2003). This can lead to more medical issues that can further deteriorate their mental/physical health.

The primary purpose of this study was to identify if a relationship exists between anxiety scores and nutrient intake in undergraduate college students at a Midwestern

University. During this study, it was hypothesized that there would be a relationship between anxiety score and nutrient intake in undergraduate students at Kent State

University’s main campus. Therefore, research needs to be conducted in order to analyze if there actually is a relationship between anxiety score and nutrient intake in college students.

Methodology

Participants were undergraduate college students at Kent State University’s main

campus enrolled in courses for the 2019 academic semester. A convenience sample was utilized. The number of students who participated in this study was 93 (n=93). The inclusion criteria for participants were that they had to be between the ages of 18-24 years old, they had to be an undergraduate student, and had not been previously diagnosed with an anxiety disorder. If any of the participants were not of age, were

graduate students or above, and had been diagnosed with an anxiety disorder, they were immediately taken to the end up of survey and were not able to continue to answer anymore of the questions.

Instrumentation

A survey was created and included demographic questions (part I) and GAD-7 anxiety scale (part II). After the participants completed parts I and II of the survey, they could then complete part III. Part III of the study used the Automated Self-Administered

(ASA) 24-hour dietary recall website from the National Cancer Institute. The students then had to use this website tool to track their food intake from the past 24-hours.

Part I of the survey was comprised of a total of ten questions regarding the demographics of the individual answering. This included age, birthday, sex, ethnicity, living status, and student class level. The rest of the questions were related to anxiety.

These questions focused more on if the individual was experiencing any anxiety, did they tend to eat more or less. If they ate more, they were asked what types of food and if they ate less, they were asked why.

Part II of the survey focused on the GAD-7 anxiety scale and consisted of seven statements. The participants had to rate how much anxiety they have been experiencing

over the past 2 weeks. The answers to the questions could be “not at all sure,” “several days,” “over half the days,” or “nearly every day.” The responses were then scored between the range of zero to three. Zero being the “not at all sure” response and three being the “nearly every day” response. The scores for each column were then added at the bottom of the scale. All of those scores were totaled at the end to give a total number

for the GAD-7 anxiety scale. This range could be anywhere zero-21. Zero meaning the individual was not experiencing any anxiety and 21 meaning they were experiencing a large amount if anxiety.

Part III of the survey required the individual to click on the link provided by the researcher to be taken to the ASA 24-hour dietary recall website. This is a website that was created through the National Cancer Institute that allows for an individual to log their dietary intake from the past 24-hours. This website generated the calories (kcals), carbohydrates (grams), fat (grams), protein (grams), sodium (milligrams), and sugar

(grams) content that the individual consumed that day. In order for the individual to have access to the link, they first needed a username and password generated by the researcher.

Data Collection Procedures

This research was approved by the Institutional Review Board (IRB) at Kent State

University. The Kent State University’s main campus undergraduate students were recruited through their university e-mail. The e-mails were obtained though the Kent

State University Registrar Office. This e-mail included the survey attachments for parts I and II. After finishing part II, the students e-mailed the researcher to receive a link

(https://asa24.nci.nih.gov/) with a username and password attached that they used to

record their 24-hour dietary recall. The survey was created using the website called

Qualtrics. This is an online web program that is available to the public. The first 10 students to complete parts I, II, and III of the survey received a small incentive of a $10 amazon gift card. Students were given a total of two weeks to complete the survey.

Data Analysis Procedures

The data collected from the survey were organized, prepared for analysis and were then run through the Statistical Package for Social Sciences (SPSS) version XII.

Analysis was conducted using descriptive statistics in regard to the demographics sections to find means and standard deviations. The GAD-7 anxiety scale was analyzed by generating a number for the individual that signified their level of anxiety. The ASA

24-hour dietary recall is a computer program that generates the number of calories, macronutrients, and micronutrients consumed based on the 24-hour log that was entered into the program. The calories (kcals), carbohydrates (grams), protein (grams), fat

(grams), sodium (milligrams), and sugar (grams) were analyzed using Pearson’s correlation to find the relationship between the variables of anxiety and nutrient intake by using the coefficient, r.

Results

Of the 21,308 students that parts I and II of the survey were sent to, 772 students opened and started the survey and 504 fully completed the first two parts. Of the 504 students who completed parts I and II, 310 students e-mailed the researcher to receive the information to complete part III. Of the 310 students that received the information, 302 actually logged into the recall tool. Of the 302 that logged in, 172 students fully

completed part III. After joining parts I and II to part III of the survey using the participants birthdates, 93 (n=93) students surveys were used for data analysis. The other

79 students were omitted because of incomplete data and duplicate birthdays.

The participants included 73 (78.4%) females and 16 (17.2%) males. Most of the students were Caucasian (80.6%) followed by African American (9.6%), then Asian at

4.3%, and Hispanic at 2.1%. In regard to living arrangements, the majority of the participants lived on campus (44.0%) followed by off campus with a roommate at 27.9% and at home with family at 18.2%. The other options were off campus alone (3.2%) and off campus with a significant other (4.3%). The class standing of the participants varied.

There were 30 (32.2%) freshman, 15 (16.1%) sophomores, 18 (19.4%) juniors, and 30

(32.3%) seniors.

There were two questions asked during the demographic section of the survey.

The first question was “do you tend to eat more than usual when experiencing anxiety? If so, what types of foods do you usually consume?” Of the 93 participants that were analyzed, 52 (55.9%) of them answered this question “yes” and 41 (44.1%) answered

“no.” The second question was “do you tend to eat less than normal during anxious times? If so, why?” Of the 93 participants, 43 (46.2%) answered “yes” to this question and 50 (53.8%) answered “no.”

Table 7 below shows the mean and standard deviation of the descriptive statistics the study analyzed: anxiety score, calories, carbohydrates, protein, fat, sodium and sugar.

Of the 93 participants anxiety scores, 51 of them scored between the range of 0-7. 32 of the students average score for their anxiety level was between 8-14 and 10 of the students

scored between 15-21.

Table 7

Mean and Standard Deviation of Anxiety Score, Calories, Carbohydrates, Protein, Fat,

Sodium, and Sugar Intake in Undergraduate College Students (n=93)

Statistic Mean Standard Deviation

Anxiety Score 7.87 4.95

Calories (kcal) 1833.11 1020.64

Carbohydrates (grams) 234.38 131.04

Protein (grams) 65.17 43.95

Fat (grams) 76.96 76.15

Sodium (milligrams) 3183.83 1891.91

Sugar (grams) 96.01 73.97

Pearson’s correlation was used to analyze the correlation between the anxiety score and calories, carbohydrates, protein, fat, sodium, and sugar. Table 8 below shows the results of the data. The correlational matrix showed there was a significant correlation between anxiety score and fat intake (r=.207, P=.046).

Table 8

Pearson’s Correlation Matrix Results of Anxiety Score1 and Nutrient Intake2 of

Undergraduate College Students (n=93)

Calories Carbohydrates (g) Protein Fat Sodium (mg) Sugar (kcals) (g) (g) (g) Anxiety Score .185 .185 .085 .207* .168 .188

Sig. (2-tailed) .075 .075 .416 .046* .108 .071

* represents a significant relationship between anxiety score and nutrient intake 1 represents anxiety score based on the GAD-7 anxiety scale 2 represents the 24-hour dietary recall based on the results of the ASA 24-hour dietary recall tool

Discussion

The purpose of this study was to identify if a relationship exists between anxiety scores and nutrient intake in undergraduate college students at a Midwestern University.

The results of the study showed that there was a significant correlation between anxiety level and fat intake. The results did not find a significant relationship between anxiety scores and calories, protein, carbohydrates, sodium, or sugar. Therefore, the hypothesis was partially accepted, and the null hypothesis was rejected.

The demographic data this study collected was fairly consistent with the demographic data of Kent State University Students. According to the Kent State

Student Body Profile, 63% of the students are female and 37% of them are male. Also,

71.4% of the Kent State college student population is Caucasian (Kent State University).

Both of these demographics align with this study. This was a relevant representative sample of the Kent State University students who reside on Kent’s campus.

The demographic data of Kent State University students showed that there is an average of 21,036 undergraduate students currently enrolled as of Fall 2019 (Kent State

University). Of the 21,036 students, 6,500 (30.9%) of them live on Kent’s Campus. The study showed that of the 93 students, 44% of them reported living on campus. This is fairly consistent with the Kent State demographics. Of the 21,036 undergraduate students,

5,095 (24.2%) of them are freshman, 4,843 (23.0%) are sophomores, 4,780 (22.7%) are juniors, and 6,318 (30.0%) are seniors (Kent State University). The study had the lowest participation from sophomores and juniors, which is consistent when looking at the class level distribution of Kent State University.

Previous research has indicated that anxiety does have an effect on poor dietary choices for college students (Kandiah et al, 2006; Haberman & Luffey, 1998; Journal of

American College Health 2010). Researched showed that the current average intake of saturated fat is nearly double what is recommended (USDA, 2015). It was found that college students tend to consume foods higher in sugar and fat leading to weight gain.

Roughly 60% of college students weight gain is in body fat rather than muscle (Kandiah et al, 2006; Journal of American College Health, 2010; Haberman & Luffey, 1998). It was also proven that a high prevalence of unhealthy diets exists among college students and a very small percentage of them actually follow the acceptable macronutrient distribution range (AMDR) for fat in their diet (Journal of American College Health,

2010). This study did find a relationship between anxiety level and fat intake, so this statistic is supported by previous research.

Studies have indicated that there is a high prevalence of mental illness within the college student population, specifically anxiety/depression. (Dusselier et al, 2005;

Mahmoud et al, 2012; Beck & Clark, 1997; Beiter et al, 2015). The average anxiety score from the study was 7.87 out of 21 with a standard deviation of 4.95. Previous research found that college students tend to experience high levels of anxiety and depression while in school (Dusselier et al, 2005; Mahmoud et al,, 2012; Beck & Clark,

1997; Beiter et al, 2015). This then led to poor dietary choices, one of them specifically being a high fat intake (Kandiah et al, 2006; Haberman & Luffey, 1998; Journal of

American College Health 2010). The results from this study support the correlation between anxiety scores and high fat intake. The anxiety scores were distributed fairly equal between the ranges of 0-7, 8-14, and 15-21.

Limitations

As with any research design, there were limitations that existed within this study.

The first limitation was the length of the survey. The three-part survey took approximately 45 minutes total to complete all three parts. The second limitation was how parts I and II were linked to part III of the survey. Since the third part of the survey was done through an outside web program, the information from part III needed to correlate to parts I and II of the survey. All three parts were correlated using the individuals’ birthdays (month/date/year). The third limitation includes self-reported data.

Survey responses were self-reported, and the validity of the data cannot be guaranteed.

Lastly, the use of convenience sample also presents as a limitation because there may be biases present within the college students’ population.

Applications

The current study showed that college students who are more anxious tend to have a higher intake of high fat foods. This could be due to the fact that college students crave unhealthy comfort foods especially during stressful situations. If a college student is feeling overwhelmed, which is very common within this population, they may tend to consume more processed foods. Most of the time these processed foods are high in fat, sugar, and sodium. They may tend to consume this type of food because of how convenient the processed food is to have on hand. Colleges and universities can offer mental health classes, more nutritious food on campus, and include a mental health department at their health center to help their students.

This information would be helpful for dietitians to know when working with this population because they can try to give advice on healthy options for college students to eat when feeling stressed. These options could be lower in fat but still satisfy the craving they are experiencing. These dietitians could also work with the on-campus dining services and offer more nutritious meals, specifically later at night. Students may then be more willing to grab the healthier option if it is available to them.

Conclusion

Overall, the findings from this study identified that there was a significant relationship between anxiety level and fat intake in undergraduate college students. This study did not find a significant relationship between anxiety level and calories, carbohydrates, protein, sodium, or sugar. College campuses should try to offer healthier food options especially during the more stressful weeks for students. These options could

be lower in saturated and trans fats. The students might be more willing to choose the healthier foods if they had the opportunity to. Research conducted in the future might want to look into better determining the college student’s anxiety score and a quicker way conduct the 24-hour dietary recall.

APPENDICES

APPENDIX A

IRB APPROVAL

Appendix A

IRB Approval

APPENDIX B

DEMOGRAPHIC QUESTIONS AND GAD-7 ANXIETY SCALE

Appendix B

Demographic Questions and GAD-7 Anxiety Scale

Skip To: End of Survey If The Relationship between Anxiety Level and Nutrient Intake in Undergraduate College Students Befo... = I disagree End of Block: Block 3

Start of Block: Default Question Block

Q1 Are you 18-24 years old?

o Yes (1) o No (2)

Skip To: End of Survey If Are you 18-24 years old? = No

Q19 What is your birthday? Example: 01/13/1997 (month/day/year)

______

Q2 What is your current class standing?

o Freshman (1) o Sophmore (2) o Junior (3) o Senior (4) o Graduate student or above (5)

Skip To: End of Survey If What is your current class standing? = Graduate student or above

Q3 Have you ever been medically diagnosed with an anxiety disorder?

Yes (1) o

No (2) o

Skip To: End of Survey If Have you ever been medically diagnosed with an anxiety disorder? = Yes

Q4 What is your sex?

o Male (1) o Female (2) o Prefer not to answer (3)

Q5 What is your ethnicity? (may select multiple)

▢ White/Caucasian (1)

▢ Black/African American (2)

▢ Hispanic/Latino (3)

▢ Asian/Pacific Islander (4)

▢ American Indian/Native American (5)

▢ Other (please specify) (6) ______

Q6 Where do you currently live?

o On-campus (1)

o At home with family (2)

Off-campus alone (3) o

Off-campus with roomate(s) (4) o

o Off-campus with significant other (5) o Other (please specify) (6) ______

Q7 Have you ever experienced any type of anxiety or overwhelming, anxious feeling before?

o Yes (1) o No (2)

Q8 When you are feeling stressed or anxious do you tend to eat more than you normally eat? If yes, please specify the foods you consume.

o Yes (1) ______o No (2)

Q9 When you are feeling stressed or anxious do you tend to eat less food than normal? If yes, please specify why.

o Yes (1) ______o No (2)

End of Block: Default Question Block

Start of Block: Block 1

Q10 Over the last 2 weeks, how often have you been bothered by the following problems? Not at all sure Several Day Over half the Nearly

(0) (1) days (2) everyday (3) Feeling nervous, anxious, or on o o o o edge (1) Not being able to stop or control worrying (2) o o o o Worrying too much about different things (3) o o o o

Trouble relaxing (4) o o o o Being so restless that it's hard to sit still (5) o o o o Becoming easily annoyed or irritable (6) o o o o Feeling afraid as if something awful might happen (7) o o o o

APPENDIX C

RECRUITMENT E-MAIL

Appendix C

Recruitment E-mail

Re: Graduate Nutrition Survey – Chance for 10 students to win a $10 amazon gift card!

Dear Perspective Survey Participant,

My name is Isabella Biasi and I am a dietetic intern and graduate student in the Nutrition and Dietetics department at Kent State University. I am writing to let you know about an opportunity to participate in a voluntary research study about the relationship between anxiety levels and nutrient intake in undergraduate college students.

Undergraduate students who are between the ages of 18-24 and have not been diagnosed with an anxiety disorder by a medical professional are eligible to participate in this survey. There are 3 parts to the survey which in total will take 45 minutes to complete. The first 10 students to complete all 3 parts of the survey will receive a $10 Amazon gift card.

In order to participate in this study, you will be asked to complete an online consent form before the confidential survey will begin.

Parts 1 and 2 of the confidential survey can be found at this link and will take approximately 10-15 minutes to complete:

To complete part 3 of the confidential survey, please email me at [email protected]. I will respond with a link to part 3 of the survey and a username and password for you to use for the link. Part 3 will take approximately 30 minutes to complete.

If you would like additional information about this study, please contact me at [email protected].

Thank you for your time!

Isabella Biasi Graduate Nutrition and Dietetics Student Dietetic Intern Kent State University

APPENDIX D

STUDY CONSENT FORM

Appendix D

Study Consent Form

The Relationship between Anxiety Level and Nutrient Intake in Undergraduate College Students Before taking part in this study, please read the consent form below and click on the "I Agree" button at the bottom of the page if you understand the statements and freely consent to participate in the study.

Consent Form

This study involves a web-based experiment designed to look at the correlation between anxiety level and nutrient intake in undergraduate college students. The study is being conducted by Professor Natalie Caine-Bish of Kent State University, and it has been approved by the Kent State University Institutional Review Board. No deception is involved, and the study involves no more than minimal risk to participants (i.e., the level of risk encountered in daily life).

This study will use a 3-part survey to determine the relationship between anxiety levels and nutrient intake in undergraduate college students. The first part of the survey will ask demographic questions. The second part will be the GAD-7 anxiety scale where the students will have to rate their anxiety levels on a scale of 0-3 by answering a few questions. The third part of the survey will be the 24-hour dietary recall. This will be a confidential survey that will take roughly 45 minutes to complete all three parts. The exclusion criteria will be that the students are 18-24 years old, undergraduate students, and not have a medical diagnosis for anxiety. All parts of the survey will be completed online and distributed though KSU email.

All responses are treated as confidential, and in no case will responses from individual participants be identified. Rather, all data will be pooled and published in aggregate form only. Participants should be aware, however, that the experiment is not being run from a "secure" https server of the kind typically used to handle credit card transactions, so there is a small possibility that responses could be viewed by unauthorized third parties (e.g., computer hackers).

Many individuals find participation in this study enjoyable, and no adverse reactions have been reported thus far.. Participation is voluntary, refusal to take part in the study involves no penalty or loss of benefits to which participants are otherwise entitled, and participants may withdraw from the study at any time without penalty or loss of benefits to which they are otherwise entitled.

If participants have further questions about this study or their rights, or if they wish to lodge a complaint or concern, they may contact the principal investigator, Professor Natalie Caine-Bish, at 330-672-2197; or the Kent State University Institutional Review Board, at (330) 672-2704.

If you are 18 years of age or older, understand the statements above, and freely consent to participate in the study, click on the "I Agree" button to begin the experiment.

I Agree I Do Not Agree

REFERENCES

AERD Statistics. (2018). Pearson Product-Moment Correlation. Retrieved from

https://statistics.laerd.com/statistical-guides/pearson-correlation-coefficient -

statistical-guide.php.

American College Health Association. (2005). American College Health Association-

National college health assessment Spring 2007 reference group data report

(abridged). Journal of American College Health, 56, 469–480.

American Heart Association. (2019). Retrieved October 15, 2019, from https://www.heart.org/.

American Heart Association. (2019). Dietary Fats. Retrieved from

https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/fats/dietary-fats.

Anxiety and Depression Association of America. (2018). Home. Retrieved from

https://adaa.org/

Beck, A., & Clark, D. A. (1997). An information processing model of anxiety: Automatic

and strategic processes. Behaviour Research and Therapy, 35(1), 49–58.

Beiter, R., Nash, R., Mccrady, M., Rhoades, D., Linscomb, M., Clarahan, M., & Sammut,

S. (2015). The prevalence and correlates of depression, anxiety, and stress in a

sample of college students. Journal of Affective Disorders, 173, 90-96.

doi:10.1016/j.jad.2014.10.054

Canetti, L., Bachar, E., & Berry, E. M. (2002). Food and emotion. Behavioural

Processes, 60(2), 157-164.

Center for Disease Control. (2000). National Health and Nutrition Examination Survey

(NHANES). Intake of Calories and Selected Nutrients for the United

Population, 1999-2000. Retrieved from

https://www.cdc.gov/nchs/data/nhanes/databriefs/calories.pdf

Center for Nutrition Policy and Promotion. (2007). Center for Nutrition Policy and

Promotion. Retrieved from https://fns-

prod.azureedge.net/sites/default/files/nutrition_insights_uploads/Insight36.pdf

Chen, Y. W., & Dilsaver, S. C. (1995). Comorbidity of panic disorder in bipolar illness:

Evidence from the Epidemiologic Catchment Area Survey. The American Journal

of Psychiatry, 152(2), 280. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/7840367.

Clifford, J., Neubaum, K., & Bellows, L. (2015). Dietary Fiber. Colorado State

University Extension. Retrieved from

https://extension.colostate.edu/docs/pubs/foodnut/09333.pdf.

Diagnostic and Statistical Manual of Mental Disorders: DSM-5. (2017). New Delhi:

CBS & Distributors, Pvt.

Digital Communications Division. (2015). What are the five major types of anxiety

disorders? Retrieved from https://www.hhs.gov/answers/mental-health-and-

substance-abuse/what-are-the-five-major-types-of-anxiety-disorders/index.html.

Dusselier, L., Dunn, B., Wang, Y., Shelley II, M. C., & Whalen, D. F. (2005). Personal,

health, academic, and environmental predictors of stress for residence hall

students. Journal of American College Health, 54(1), 15–24.

Fairburn, C. G., & Brownwell, K. D. (2005). Eating Disorders and Obesity: A

Comprehensive Handbook. New York: Guilford.

Fava, M., Rankin, M. A., Wright, E. C., Alpert, J . E., Nierenberg, A. A., Pava, J., &

Rosenbaum, J. F. (2000). Anxiety disorders in major depression. Comprehensive

Psychiatry, 41(2), 97-102. doi:10.1016/s0010-440x(00)90140-8

Feske, U., Frank, E., Mallinger, A. G., Houck, P. R., Fagiolini, A., Shear, M. K.,

…Kupfer, D. J. (2000). Anxiety as a correlate of response to the acute treatment

of bipolar I disorder. American Journal of Psychiatry, 157(6), 956-962.

Fulgoni, V. L., III. (2008). Current protein intake in America: Analysis of the national

health and nutrition examination survey, 2003–2004. The American Journal of

Clinical Nutrition, 87(5), 1554S-1557S.

Ganley, R.M. (1989). Emotion and eating in obesity: A review of the literature.

International Journal of Eating Disorders 8, 343-361.

Gariepy, G., Nitka, D., & Schmitz, N. (2009). The association between obesity and

anxiety disorders in the population: a systematic review and meta-

analysis. International Journal of Obesity, 34(3), 407–419. doi:

10.1038/ijo.2009.252

Gropper, S. S., Simmons, K. P., Gaines, A., Drawdy, K., Saunders, D., Ulrich, P., &

Connell, L. J. (2009). The freshman 15—A closer look. Journal of American

College Health, 58(3), 223–231. doi: 10.1080/07448480903295334

Haberman, S., & Luffey, D. (1998). Weighing in college students diet and exercise

behaviors. Journal of American College Health, 46(4), 189–191. doi:

10.1080/07448489809595610

Hinrichsen, H., Wright, F., Waller, G., & Meyer, C. (2003). Social anxiety and coping

strategies in the eating disorders. Eating Behaviors, 4(2), 117-126.

Hirschfeld, R. M. (2001). The comorbidity of major depression and anxiety disorders:

Recognition and management in primary care. Primary care companion to the

Journal of clinical psychiatry, 3(6), 244-254.

Huang, T. T.-K., Harris, K. J., Lee, R. E., Nazir, N., Born, W., & Kaur, H. (2003).

Assessing overweight, obesity, diet, and physical activity in college students .

Journal of American College Health, 52(2), 83–86. doi:

10.1080/07448480309595728

Iron Disorders Institute. (2019). Iron We Consume. Retrieved April 1, 2019, from

http://www.irondisorders.org/iron-we-consume/.

Kandiah, J., Yake, M., Jones, J., & Meyer, M. (2006). Stress influences appetite and

comfort food preferences in college women. Nutrition Research, 26(3), 118-123.

Kazdin, A. E. (2000). Encyclopedia of Psychology (Vol. 8). Washington, DC: American

Psychological Association.

Kauer-Sant’Anna, M., Frey, B. N., Andreazza, A. C., Ceresér, K. M., Gazalle, F. K.,

Tramontina, J., . . . Kapczinski, F. (2007). Anxiety comorbidity and quality of life

in bipolar disorder patients. The Canadian Journal of Psychiatry,52(3), 175-181.

doi:10.1177/070674370705200309.

Kessler, R. C., Soukup, J., Davis, R. B., Foster, D. F., Wilkey, S. A., Van Rompay, M. I.,

& Eisenberg, D. M. (2001). The use of complementary and alternative therapies

to treat anxiety and depression in the United States. American Journal of

Psychiatry, 158(2), 289-294.

Lepp, A., Barkley, J. E., & Karpinski, A. C. (2013). The relationship between cell phone

use, academic performance, anxiety, and satisfaction with life in college students .

Computers in Human Behavior, 31, 343-350. doi:10.1016/j.chb.2013.10.049

Lykouras, L., & Michopoulos, J. (2011). Anxiety disorders and obesity.

Psychiatriki, 22(4), 307-313. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/22271843.

Lyman, B. (1982). The nutritional values and food group characteristics of food preferred

during various emotions. Journal of Psychology, 112, 121-127.

Macht, M. (1999). Characteristics of eating in anger, fear, sadness and joy. Appetite, 33,

129-139.

Macht, M., & Simons, G. (2000). Emotions and eating in everyday life. Appetite, 35, 65-

71.

Mahmoud, J. S. R., Staten, R. T., Hall, L. A., & Lennie, T. A. (2012). The relationship

among young adult college students’ depression, anxiety, stress, demographics,

life satisfaction, and coping styles. Issues in Mental Health Nursing, 33(3), 149-

156.

Merriam-Wesbster Dictionary. Anxiety. (2019). Retrieved from https://www.merriam-

webster.com/dictionary/anxiety?src=search-dict-box

Mitchell, J. E., Pyle, R. L., Hatsukami, D., & Eckert, E. D. (1986). What are atypical

eating disorders? Psychosomatics, 27(1), 28.

Moreira, F. A., & Crippa, J. A. (2009). The psychiatric side-effects of rimonabant.

Brazilian Journal of Psychiatry, 31(2). Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/19578688

National Cancer Institute. (2019). Comprehensive Cancer Information. Retrieved

October 23, 2019, from https://www.cancer.gov/.

National Institute of Health. (2018). Anxiety Disorders. Retrieved from

https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

National Institute of Health. (2019). Automated Self-Administered 24-Hour (ASA24®)

Dietary Assessment Tool. Retrieved from https://epi.grants.cancer.gov/asa24/

Patel, K.A., & Schlundt, D.G. (2001). Impact of moods and social context on eating

behavior. Appetite, 36, 111-118.

Peterson, L. G., & Pbert, L. (1992). Effectiveness of a meditation-based stress reduction

program in the treatment of anxiety disorders. American Journal of

Psychiatry, 149(7), 936-943.

Rapaport, M. H., Clary, C., Fayyad, R., & Endicott, J. (2005). Quality-of-life impairment

in depressive and anxiety disorders. American Journal of Psychiatry, 162(6),

1171-1178.

Simon, N. M., Smoller, J. W., Fava, M., Sachs, G., Racette, S. R., Perlis, R., ... &

Rosenbaum, J. F. (2003). Comparing anxiety disorders and anxiety-related traits

in bipolar disorder and unipolar depression. Journal of Psychiatric

Research, 37(3), 187-192.

Smith -Jackson, T., & Reel, J. J. (2012). Freshmen women and the “Freshman 15”:

Perspectives on prevalence and causes of college weight gain. Journal of

American College Health, 60(1), 14–20. doi: 10.1080/07448481.2011.555931

Spitzer, R.L., Kroenke, K., Williams, J.B.W., & Lowe, B. (2006). A brief measure for

assessing generalized anxiety disorder. Arch Inern Med. 166:1092-1097.

Strine, T. W., Mokdad, A. H., Balluz, L. S., Gonzalez, O., Crider, R., Berry, J. T., &

Kroenke, K. (2008). Depression and anxiety in the United States: Findings from

the 2006 behavioral risk factor surveillance system. Psychiatric Services, 59(12),

1383-1390.

Ströhle, A. (2008). Physical activity, exercise, depression and anxiety disorders. Journal

of Neural Transmission, 116(6), 777.

Student Body Profile. (n.d.). Retrieved October 19, 2019, from

https://www.kent.edu/Array/student-body-profile.

Taylor, C. T., Hirshfeld-Becker, D. R., Ostacher, M. J., Chow, C. W., Lebeau, R. T.,

Pollack, M. H., . . . Simon, N. M. (2007). Anxiety is associated with impulsivity

in bipolar disorder. Journal of Anxiety Disorders, 22(5), 868-876.

doi:10.1016/j.janxdis.2007.09.001

United States Department of Agriculture. (2015). Retrieved from

https://www.nass.usda.gov/Publications/Ag_Statistics/2015/index.php.

U. S. Department of Agriculture. (2018, September 5). Dietary Guidelines. Retrieved

from https://www.choosemyplate.gov/dietary-guidelines

Willett, W., Stampfer, M. (1986). Total Energy Intake: Implications for Epidemiologic

Analyses. American Journal of Epidemiology, Volume 124, Issue 1, July 1986,

Pages 17–27, https://doi.org/10.1093/oxfordjournals.aje.a114366

Westerterp, K. R. (2004). Diet induced thermogenesis. Nutrition & Metabolism, 1(1), 5.

Willett, W., & Stampfer, M. J. (1986). Total energy intake: implications for

epidemiologic analyses. American Journal of Epidemiology, 124(1), 17-27.

Zwaan, M. D. (2001). Binge eating disorder and obesity. International Journal of

Obesity, 25(S1). doi:10.1038/sj.ijo.0801699